“Death on Wheels” in sub-Saharan Africa: How to prevent it?

On the eve of the 2010 World Football Cup, former South Africa President Nelson Mandela experienced a tragedy that is all too common across sub-Saharan Africa: his great-granddaughter was killed in a car crash returning home after a concert in Soweto. The car's driver was arrested and charged with drunk driving.

Thousands of African families have experienced the pain of the Mandela family: according to WHO data, close to 250,000 people die each year on African roads, representing one-fifth of the world's road deaths, and about 500,000 sustain non-fatal injuries.

Severe underreporting hides the real magnitude of the problem; for example, in Mozambique, estimates done in 2011 by a Harvard University team indicated that road deaths and non-fatal injuries were twice as high as those reported in official statistics.

As the map shows, the sub-Saharan African countries, with an estimated death rate of 32.2 people per 100,000 population, have some of the highest road death rates in the world although they possess only 2% of the world’s registered vehicles.

This rate is double the average rate for Latin America and South-East Asia, and is more than five times that of best road safety performers (Sweden, UK, and Netherlands). Road traffic injuries are already the fourth leading cause of death in people aged 15–44 years; for young men, they are the second leading cause of premature death after HIV/AIDS.

With rapid urbanization, economic growth and higher incomes, and increasing numbers of cars and two wheelers operating in poor road networks, the number of road deaths is predicted to rise in sub-Saharan Africa by at least 80% by 2020 if nothing is done to improve road conditions and traffic safety. Vulnerable road users, such as pedestrians, cyclists, motorcyclists and passengers using unsafe public transport, suffer greatest as they account for more than 50% of road deaths.

The economic cost of road traffic deaths and injuries has been estimated at 1-3 percent of GDP in most countries (WHO/World Bank 2004). This cost reflects the value of medical services used to treat injured people, insurance administration, forgone individual or family earnings, and business costs such as those due to temporary or permanent disability of employees and delayed delivery of goods and services. Road injuries are also a major burden on already overburdened health systems.

So what is needed to make African roads safer?

Good roads are now seen as a critical investment for enhancing competitiveness and resilience in sub-Saharan Africa since they facilitate the movement of people, goods, and services and access to essential services. With the adoption of the 2011-2020 UN Decade of Action on Road Safety, African governments are also committed to reducing the heavy social toll imposed by road traffic injuries. So, too, are international organizations, despite the fact that in many infrastructure projects funded by multilateral development banks, road safety has often been merely an afterthought.

While economic aspirations and political declarations help, international experience makes it clear that making roads safer presumes the adoption of a “safe system approach” to make a country response effective and sustainable. Indeed, the reality in most of sub-Saharan Africa reflects the need to painstakingly build institutions and capacity to plan, manage and implement road safety initiatives at national scale rather than just adopting parallel or isolated sectoral interventions. A 2009 assessment by WHO covering 41 African countries evidenced this reality:

While the majority (88%) of the countries reported having a road safety agency, in only 10 (24%) has the government endorsed a strategy with targets and earmarked funding.

Most countries not only lack comprehensive road safety laws to address the main risk factors (speed, drunk driving, not wearing seat belts or helmets, using cell phones or texting while driving), but also suffer from sporadic enforcement, where bribes often prevent penalizing drivers who knowingly break traffic rules.

The availability of quality data to accurately assess the problem is limited in most countries, constraining planning, monitoring and impact evaluation efforts.

While 40% of countries reported having a formal emergency medical care system with a national access telephone number, their capacity and quality are poor. In most countries, emergency medical services are usually a marginal element of road safety programs as they are commonly equated with simple transportation arrangements (ambulance service). But to save thousands of lives and prevent long-lasting disabilities, interconnected systems are required to offer a “continuum of care” from first contact with a victim (communication and transport systems, well-trained paramedics), to medical care provided at different health system levels in accordance to the needs of the injured.

The adoption by governments and international agencies of “shared value” principles (Porter and Kramer 2011), which combine economic and social concerns, could help redress Africa’s road infrastructure deficits that hinder economic growth while addressing the societal harm caused by road traffic injuries and premature deaths. This type of approach is needed to generate collective action by winning political and community support to implement the African Road Safety Action Plan 2011-2020 that was adopted in Addis Ababa last year, forging public and private partnerships to share the cost of enhanced infrastructure and interventions, and building institutional and management capacity to effectively deal with road safety challenges.

Moving forward, all of us will do well to keep in mind the words of Desmond Tutu, the Emeritus Archbishop of Cape Town and 1984 Nobel Peace Prize Laureate, who noted that “From time to time in human history there comes a killer epidemic that is not recognized for what it is and is not acted against until it is almost too late. HIV/AIDS, which is ravaging Sub-Saharan Africa, is one such. Road traffic injuries have the potential to be another."

The article focused on automobiles, but international experience suggests that it may be worth a specific look at pedestrian and bicycle/motorcycle deaths, as these groups are the most vulnerable road users and deaths can be greatly reduced by the introduction of helmets and/or primary school interventions related to road safety training. Beyond the direct impact, primary age kids have a strong influence on parental behavior.
Also, with regard to statistics, the figures cited are the official statistics, so one can probably assume the actual rates of death are 2-3 times reported levels, for reasons cited with regard to M&E and the fact that police/medical services usually attend only around have of incidents and deaths often happen after the fact the victim is take home from the scene or hosptial.

Thanks for your observations. In agreement with them. Indeed, as noted in the blog, vulnerable road users, such as pedestrians, cyclists, motorcyclists and passengers using unsafe public transport, suffer greatest as they account for more than 50% of road deaths. Country experience, for example in Vietnam, shows the significant impact in reducing premature deaths by the introduction and enforcement of helmet wearing initiatives and regulations.
Indeed, as also noted in the blog, the true magnitude of the problem is obscured by the underreporting of deaths and injuries. This is a major systemic issues in most of the developing countries.
Patricio

I'm afraid the thrust of this article is far too "western" by looking for information from sources outside of Africa. A drive along any African country road will explain the high level of road traffic accident (RTA's) casualties - quite simply, it is the high number of pedestrians.
South Africa is generally the best place to start looking for this information because it's probably the one African country that records this data...
Try the accident crash statistics at the Arrive Alive website (http://www.arrivealive.co.za/pages.aspx?i=2826) or the Road Traffic Management Corporation in South Africa (rtmc.co.za) as well.

Submitted by James Habyarimana and Billy Jack, Georgetown University on Thu, 09/06/2012 - 09:26

We welcome Paricio Marquez’s efforts to highlight the enormous health and economic costs of road accidents in the developing world. Attention to this global curse is long overdue, as evidenced by Mr Marquez’s observation that “death on wheels” is second only to HIV/AIDS as the leading cause of premature death among young men in sub-Saharan Africa. It is crucial to figure out, as the title of Mr Marquez’s blog promises, “how to prevent it”. Sadly, this promise is not fulfilled.
Solutions to development problems are menacingly difficult to discover, and jargon can quickly substitute for specific actions, particularly when those actions involve large, long-term investments in the context of limited resources and competing demands. But calling for a “safe system approach” and for governments to “painstakingly build institutions” seems unlikely to save many passengers or pedestrians any time soon. We don’t even know what these terms mean, in practice. How many times have developing countries been urged to build institutions? While some econometric evidence suggests they are important, is there nothing else that can be done in the short run to reduce deaths and injuries?
Cooperating with each other seems like a good start, but again, exactly what the actionable content of adopting “shared value” principles is, we don’t know. Sure, public goods such as safe roads could be financed from a variety of sources, including private equity, but is it simply a resource constraint that is killing so many people? The safety record of Nairobi’s new Chinese-financed super highways so far leaves one suspicious that private financing will automatically bring higher safety standards. Of course there is no reason to believe it will.
While we wait for countries to get rich, and for the quality of their roads and vehicles to improve in parallel with the quality of their water systems, schools, and golf courses, are there cheap solutions that can be adopted in the short term that, conditional on the physical environment in which people commute and travel, can alter the behavioral landscape? We believe that behavior change is essential to achieve drastic reductions in road deaths in the short term.
But don’t take it from us. When the manager of a matatu fleet operating in rural Kenya was asked by one of us what the primary causes of road accidents were, she remarked, “The roads don’t cause accidents, the weather doesn’t cause accidents, and lack of maintenance doesn’t cause accidents. Drivers cause accidents. They can slow down when the roads are bad, they can pull over when the rain pours, and they can refuse to drive when their vehicle is unsafe.”
If it is always the driver’s fault, should we just train them all to higher levels of proficiency? Maybe, but that too would be expensive. Poor places have low levels of all kinds of capital – physical as well as human – and augmenting either of them takes time and resources.
Instead, finding innovative ways to nudge drivers toward better driving practices, to induce them, without necessarily relying on heavy-handed law enforcement (which, as the author rightly acknowledges, is often corrupted), to internalize some of the costs they impose on others, could be a useful way of grasping at some low-hanging fruit on the road safety tree: that is, cheap interventions with large effects.
We encourage experimentation in this area, and rigorous evaluation where feasible.
James Habyarimana and Billy Jack, Georgetown University

Thanks for your important comments. While nudges are a promising behavior change tool (by the way, I read your blog and PPT on the experiment that your carried out in Kenya), in the medium term, as it is belatedly now been acknowledged in the health sector, there is no substitute for building systems. They are needed in order to sustain the effort over the longer term at the country level. And the need for systems is not theoretical jargon but it rooted on accumulated evidence from developed and developing countries. The challenge is how to support countries in ADAPTING (that is the key word, not adopting mechanically) those experiences to their specific realities and start with demonstration projects in urban areas and high-risk road corridors before rolling out to the rest of the country.
And in terms of interventions, there is not a single silver bullet. As shown by recent research, a combined intervention strategy that simultaneously enforces multiple road safety laws produces the most health gain for a given amount of investment (Chisholm et al, 2012).